Effectiveness, reach, uptake, and feasibility of digital health interventions for adults with type 2 diabetes: a systematic review and meta-analysis of randomised controlled trials
Authors: George Moschonis, George Siopis, Jenny Jung, Evette Eweka, Ruben Willems, Dominika Kwasnicka, Bernard Yeboah-Asiamah Asare, Vimarsha Kodithuwakku, Nick Verhaeghe, Rajesh Vedanthan, Lieven Annemans, Brian Oldenburg, Yannis Manios, Brian Oldenburg, Dominika Kwasnicka, Enying Gong, Jenny Jung, Bernard Yeboah-Asiamah Asare, Vimarsha Kodithuwakku, Konstantinos Votis, Sofia Segkouli, Andreas Triantafyllidis, Odysseas Kyparissis, Ioannis Paliokas, Eleftheria Polychroniou, Lieven Annemans, Nick Verhaeghe, Ruben Willems, Dirk De Craemer, Yannis Manios, Kostas Anastasiou, Konstantinos Tserpes, Christina Mavrogianni, Eva Karaglani, Electra Kalogerakou, Maria Maragkoudaki, Agathi Ntzouvani, Katerina Kontochristopoulou, Sabine Dupont, Elizabeth Dupont, Leo Dauzon, Maartje Roskams, Niamh Lennox-Chhugani, Martin Perrin, Niamh Daly Day, Georgina Ferrer, Orla Snook, Edelweiss Aldasoro, Alejandro Gil-Salmerón, Pilar Gangas Peiró, Darren Curran, Fiona Lyne, Nereide A. Curreri, George Moschonis, George Siopis, Nazzareno Pierantozzi, Claudia D'Antonio, Giacomo Vespasiani, Teresa Almonti, Helen Skouteris, Tracy Taylor, Melissa Savaglio, Konstantinos Makrilakis, George Stergiou, Stavros Liatis, George Karamanakos, Chrysi Koliaki, Anastasios Kollias, Eva Zikou, Haris Dimosthenopoulos, Rajesh Vedanthan, Keng-Yen Huang, Samrachana Adhikari, Kun Qian, Julia Dickhaus, Kimberly Carney, Evette Eweka, Farhan Sahito, Dusan Pavlovic, Djordje Djokic, Arzoo Sahito, Gisella Battalova, Chiara Seghieri, Sabina Nutti, Milena Vanieri, Nicola Belle, Gaia Bertarelli, Paola Cantarelli, Francesca Ferre, Anna Noci, Constanza Tortu, Nadia Bozzi, Dina Ferrari, Rachele Borelli, Violeta Iotova, Yoto Yotov, Natalia Usheva, Anna Kozhuharova, Vanya Russeva, Vanya Marinova, Sonya Koleva, Virginia Atanasova, Tanya Stefanova, Kaloyan Tsochev, Luis Moreno Aznar, Rosa Magallón Botaya, Gloria Bueno Lozano, Pilar De Miguel-Etayo, Esther Ma Gonzalez-Gil, María L. Miguel-Berges, Susana Pérez, Bárbara Oliván Blázquez, Natalia Giménez-Legarre, Florian Toti, Skerdi Prifti, Blerina Bombaj, Ditila Doracaj, Ornela Laze, Adriana Lapardhaja, Luftime Bruka
Journal: The Lancet Digital Health (2023)

BackgroundDigital health interventions have shown promising results for the management of type 2 diabetes, but a comparison of the effectiveness and implementation of the different modes is not currently available. Therefore, this study aimed to compare the effectiveness of SMS, smartphone application, and website-based interventions on improving glycaemia in adults with type 2 diabetes and report on their reach, uptake, and feasibility.MethodsIn this systematic review and meta-analysis, we searched CINAHL, Cochrane Central, Embase, MEDLINE, and PsycInfo on May 25, 2022, for randomised controlled trials (RCTs) that examined the effectiveness of digital health interventions in reducing glycated haemoglobin A1c (HbA1c) in adults with type 2 diabetes, published in English from Jan 1, 2009. Screening was carried out using Covidence, and data were extracted following Cochrane's guidelines. The primary endpoint assessed was the change in the mean (and 95% CI) plasma concentration of HbA1c at 3 months or more. Cochrane risk of bias 2 was used to assess risk of bias. Data on reach, uptake, and feasibility were summarised narratively and data on HbA1c reduction were synthesised in a meta-analysis. Grading of Recommendations, Assessment, Development, and Evaluation criteria was used to evaluate the level of evidence. The study was registered with PROSPERO, CRD42021247845.FindingsOf the 3236 records identified, 56 RCTs from 24 regions (n=11 486 participants), were included in the narrative synthesis, and 26 studies (n=4546 participants) in the meta-analysis. 20 studies used SMS as the primary mode of delivery of the digital health intervention, 25 used smartphone applications, and 11 implemented interventions via websites. Smartphone application interventions reported higher reach compared with SMS and website-based interventions, but website-based interventions reported higher uptake compared with SMS and smartphone application interventions. Effective interventions, in general, included people with greater severity of their condition at baseline (ie, higher HbA1c) and administration of a higher dose intensity of the intervention, such as more frequent use of smartphone applications. Overall, digital health intervention group participants had a –0·30 (95% CI –0·42 to –0·19) percentage point greater reduction in HbA1c, compared with control group participants. The difference in HbA1c reduction between groups was statistically significant when interventions were delivered through smartphone applications (–0·42% [–0·63 to –0·20]) and via SMS (–0·37% [–0·57 to –0·17]), but not when delivered via websites (–0·09% [–0·64 to 0·46]). Due to the considerable heterogeneity between included studies, the level of evidence was moderate overall.InterpretationSmartphone application and SMS interventions, but not website-based interventions, were associated with better glycaemic control. However, the studies' heterogeneity should be recognised. Considering that both smartphone application and SMS interventions are effective for diabetes management, clinicians should consider factors such as reach, uptake, patient preference, and context of the intervention when deciding on the mode of delivery of the intervention. Nine in ten people worldwide own a feature phone and can receive SMS and four in five people have access to a smartphone, with numerous smartphone applications being available for diabetes management. Clinicians should familiarise themselves with this modality of programme delivery and encourage people with type 2 diabetes to use evidence-based applications for improving their self-management of diabetes. Future research needs to describe in detail the mediators and moderators of the effectiveness and implementation of SMS and smartphone application interventions, such as the optimal dose, frequency, timing, user interface, and communication mode to both further improve their effectiveness and to increase their reach, uptake, and feasibility.FundingEU's Horizon 2020 Research and Innovation Programme.